Basic Information
Provider Information | |||||||||
NPI: | 1891776274 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MIRIN | ||||||||
FirstName: | BABAK | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MIRIN | ||||||||
OtherFirstName: | BABAK | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 405 W COUNTRY CLUB RD | ||||||||
Address2: |   | ||||||||
City: | ROSWELL | ||||||||
State: | NM | ||||||||
PostalCode: | 882015209 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5756228170 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 405 W COUNTRY CLUB RD | ||||||||
Address2: |   | ||||||||
City: | ROSWELL | ||||||||
State: | NM | ||||||||
PostalCode: | 882015209 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5756228170 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/11/2005 | ||||||||
LastUpdateDate: | 05/19/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/18/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0805X | 20020076 | NM | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry | 174400000X | 2002-0076 | NM | N |   | Other Service Providers | Specialist |   | 2084A0401X | 20020076 | NM | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine |
ID Information
ID | Type | State | Issuer | Description | 34876855 | 05 | NM |   | MEDICAID |